Dental Health Aide Program Improves Access to Oral Health Care for Rural Alaska Native People

Problem Addressed

• High prevalence of oral diseases: Alaska Native children suffer rates of dental caries (decay) that are 2.5 times the U.S. average.² American Indian and Alaska Native children between the ages of 2 and 4 have the highest rate of decay in the U.S.—five times the national average.¹ Alaska Native adults also suffer disproportionately high rates of oral disease.
• Significant impact: One-third of school-age children in rural Alaska miss school because of dental pain,² and a quarter report avoiding laughing or smiling because of the appearance of their teeth.¹ By the time they reach adulthood, many have already experienced devastating consequences due to lack of dental care.²
• Lack of access to professional care increases disparities: About 85,000 Alaska Native people live in small villages of 300-400 people, accessible only by air or water; villagers often have to travel hundreds of miles to obtain dental care.¹ There is one dentist for every 2,800 individuals in the Indian Health Services and tribal health clinics, compared with one dentist for every 1,500 individuals in the general U.S. population.¹ A scarcity of dentists of American Indian or Alaska Native ethnicity further contributes to the access problem, making it especially difficult for Alaska Native people to get culturally competent care.^1,2

Description of the Innovative Activity

• Recruitment: Regional Alaska Native health organizations recruit dental therapist candidates, mostly tribal members, in their regions. Candidates make application to the University of Washington DentEX program. In order to qualify, candidates must be high school graduates with good English language skills, have good comprehension of high school biology, and pass the Test of Adult Basic Education.
• Training: Dental therapists receive training in partnership with the University of Otago in New Zealand, an internationally recognized school of dentistry with over 85 years of experience with the dental health aide therapist model. The University of Otago curriculum for a Diploma in Dental Therapy includes courses in general health science, oral health science, society and health, clinical dentistry, and dental therapy practice. Accepted applicants complete a 2-year training program that includes 2,400 hours of classroom training and clinical experience. They spend approximately 760 hours treating children in local clinics, and their training includes 4 weeks in the field learning the responsibilities of a dental therapist. The program also recently expanded its training by forging a partnership with the University of Washington’s School of Medicine’s MEDEX Northwest, which will be sponsoring a new dental therapist education program known as Alaska DentEX.
• Protracted preceptorship: After training, dental therapists return to their home communities and undergo a 400-hour preceptorship (practical experience and training) under the supervision of a dentist who is employed by a recognized tribal health organization and located in a hospital that serves the village. The dentist is responsible for writing standing orders, being the point of contact for the dental therapist, and evaluating the dental therapist's skills through direct observation.
• Telehealth network: Each supervising dentist is located in the hub hospital that serves the respective village and is connected to the dental therapist via a telehealth network that allows the transfer of real-time digital images from remote locations, enabling the dentist to view the same teeth and X-rays as are being examined by the dental therapist. Patients whose needs are beyond the scope of a dental therapist, as well as patients with any significant health history or special needs, require a consultation with the dentist.
• Certification: The Community Health Aide Certification Board, a 12-member board of experienced Federal, State, and tribal health professionals appointed by the Indian Health Services, administers a certification program. Dental therapists must meet the qualifications outlined in the Federal Community Health Aide Program Standards and Procedures. The Board can revoke or suspend the certificates of dental therapists who do not meet competency standards. Recertification occurs biennially and requires reevaluation by the supervising dentist.
• Dental services: Dental therapists provide year-round services in regional hub clinics and remote village clinics. While the program increases access to dental services for all Alaska Native people living in rural areas, it focuses on reaching children, pregnant women, and other high-risk residents. Dental therapists treat dental caries, primarily in children, and provide preventive services, such as fluorides, sealants, cleanings, pulpotomies, and uncomplicated tooth extractions to reserve function and address pain or infection.
• Oral health education and prevention: Dental therapists provide oral health education at schools and develop community prevention strategies for their villages. For example, one of the dental therapists living in a Kotzebue village visits the local school each day to provide preventive services such as setting up tooth brushing and fluoride supplement programs and educating the children about the importance of oral health. Dental therapists also sometimes supervise primary dental health aides, whose scope of practice includes oral health education and topical fluoride application.
• Reimbursement for services provided: Under a Federal agreement, dental therapists bill the Medicaid program directly for the services they provide in order to receive reimbursement.

References/Related Articles

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Results

• Enhanced access:  As of 2009, there are 13 dental therapists serving 42 villages in Alaska, providing year-round services to thousands of Alaskans who previously had access to services only a few weeks a year. For example, the first class of dental therapists is bringing dental care to hundreds of patients in two remote Alaska villages who previously had limited or no access to such services.
  • Between February 1, 2005 and August 31, 2005, the two dental therapists in Bethel completed 375 exams, 519 preventive services, 242 restorations, 13 stainless steel crowns, 16 pulpotomies, and 171 extractions.
  • In this same period the two dental therapists in Kotzebue saw 857 patients and completed 390 exams, 745 preventive services, 576 restorations, and 89 extractions.
  • Before the dental therapist program these villages typically received between 1 and 2 weeks of access to itinerant dental care from a visiting dentist. Now with a dental therapist these same communities have year-round access to basic safety net services.
  • Between 2007 and 2009 the number of villages served doubled from 20 to 42.
• High-quality, effective care: Two independent evaluators found the Alaska program to be of very high quality.
  • A professor of dentistry from the University of Washington found that the first four dental therapists employed in Alaska met evaluators’ standards for record review, cavity preparation and restoration, patient management, and patient safety. He recommended that the program not only continue but be expanded.³
  • A professor of dentistry from Texas A&M University concluded that the dental treatment performed by dental therapists was within their scope of training, delivered in a safe manner, and met the standard of care of the dental profession. He also found no statistically significant difference in the rate of complications resulting from treatment delivered by dental therapists versus dentists.⁴

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Conceptualizing the model: Concurrent with the discussions described in the previous section, the Alaska Native Tribal Health Consortium and its component tribes began the development of dental health aides, under the provisions of the Community Health Aide program. Project leaders conceptualized three levels of dental health aides, including the primary dental health aide, the expanded function dental health aide, and the dental therapist. Both the primary and extended function dental health aides would work under the direct supervision of a dentist, while the dental therapist would be trained to work in consultation with a dentist.
• Training agreement and initial funding: In 2003, the School of Dentistry at the University of Otago in New Zealand agreed to accept six Alaska Native students per year into their dental therapy training program. Project leaders chose this school because it is an internationally recognized school of dentistry with over 85 years of experience with the dental therapist practice model. At the time, there was no such program in the U.S. Initial funding to support training and travel was obtained from the Rasmuson Foundation.
• Initial class: The first six students entered training in February 2003, with four of the six completing training in December 2004 and starting their preceptorships in January 2005 in the villages of Bethel and Kotzebue. One more student completed the curriculum and started the preceptorship in Kotzebue in August 2005.

Resources Used and Skills Needed

• Staffing: The clinical program director is a dentist who oversees training of dental therapy students. Visiting faculty give lectures to dental therapists at clinics as part of their training. A nurse coordinator handles administrative work and student support work, including assistance with housing and travel. Dentists and hygienists, who may already be employed in regional or village clinics, also constitute members of the dental team.
• Costs: The total cost of training an Alaska Native student in New Zealand (including travel, books, and tuition) is approximately $50,000 to $60,000. Operating costs include staff salaries and benefits, equipment costs, and other ongoing expenses.

Funding Sources

Robert Wood Johnson Foundation; Rasmuson Foundation; Paul G. Allen Charitable Trust; Ford Foundation; Alaska Mental Health Trust; Denali Commission; Natural Rural Funders; Indian Health Service (IHS); W.K. Kellogg Foundation

Getting Started with This Innovation

• Get a commitment from the community: The need for such a program must be locally driven, with the people who want health care services asking the health care community to make it happen. In this case, there was local interest in the program, because it was perceived as a good nonseasonal job opportunity for residents (allowing individuals to learn clinical skills, develop relationships with patients, and gain standing in the community) and an effective way to improve the oral health of residents.
• Work closely with the dental community to get buy-in: In “selling” the program to dentists, focus on convincing them to think of themselves as a leader of an expanded dental team, rather than as a sole provider. Also emphasize the ability of the dental therapist model to expand services to individuals who previously had little or no access to dental services at all.
• Make sure that a solid legal framework exists: State and Federal policies were critical in providing a legal basis for this program. This program is considered to be legal among rural Alaska Native people because of Federal statutes concerning tribal health. Tribal management of Indian Health Services programs is authorized by the Indian Self-Determination and Education Assistance Act. Dental therapists are able to receive certification and operate under the auspices of Alaska's Community Health Aide program, which is authorized by Section 121 of the Indian Health Care Improvement Act,⁵ not the Alaska State Medical or Dental Practice Acts. Consequently, the program can use its own certification process while others may not be legally able to do the same in other geographic areas or settings without a policy change or waiver. 

Sustaining This Innovation

• Develop a viable economic model: The ongoing operations of this program depend on reimbursement for services provided by dental therapists (e.g., through Medicaid). One of the program’s unique aspects is that it makes the provision of oral health services under the Medicaid program economically viable, something that many other dentist-based programs have failed to do.

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